From January 2023 to the end of March initially, we have been funded by Derbyshire NHS ICB to run our Winter Pressures – Home from Hospital Support

We provide support to patients over 65 that are about to be discharged from Acute hospitals, that support High Peak-based patients in the following areas:

Coverage of the following regions: High Peak

• New Mills
• Chapel en le Frith
• Whaley Bridge
• Hayfield
• Birch Vale
• Chinley
• Buxworth

Coverage in the following health trusts:

• Stepping Hill (Stockport)
• Macclesfield (East Cheshire)
• Potentially Tameside (Ashton under Lyne)
• Derbyshire acute settings

We can work with the Advance discharge teams and MDT meetings to support patients that are medically fit to be discharged, but without support would probably end up in readmission and would work with the discharge to assess teams to support ongoing care for patients.
Typically, we would offer up to 6 weeks of home visits and support with onward referrals to services and liaison with statutory services to ensure that the patients’ needs are met at home.

Up to 48 hours before discharge, a coordinator or support worker would on receipt of a referral meet the patient on ward and the ward staff and conduct a short discharge assessment and arrange for the patient to be transported home.
Interventions would include:

• Collection and ambulation to patients’ home
• Home safety check
• Befriending
• Weekly shopping trips by minibus and individual
• Refer to vol sector
• Carer support referral
• Adult social services referral
• OT referral
• Pharmacy
• Nutrition advice
• Legal and Wills
• Help from home – Foodbank
• Hamper ( £ 8 for each patient – Bread soup milk et al ) for each patient to have at home.
• Emergency plan
• Blue badge
• Rehabilitation chair-based exercises (face-to-face and by zoom)
• Fire safety check referral

We would also be able to link all patients to our existing services at the Volunteer centre.

If you are a hospital-based professional and are building a discharge plan for your patient – please complete this form, and we will make contact directly